4949b_0Y03_IELTSApplicationForm_CMYK:4949.8Y02.Print.

IELTS Application Form 17/2/10 16:19 Page 1

NOT FOR SALE

Application form

Please return to:

please attach a recent please attach a second (Centre stamp) passport-sized identical signed photograph here securely passport-sized (Note: the photograph photograph here using a must not be more paper clip than 6 months old)

PLEASE WRITE IN BLOCK CAPITALS

1 Preferred date of test d d m m y y second choice d d m m y y

2 Last (family/surname) name

3 Title (Dr/Mr/Mrs/Miss/Ms)

4 First (given) name(s)

(These names must be the same as the names on your passport/National Identity Card and must appear in the same order.)

5 Address: Please note you will only be sent one copy of your results. Please ensure the correct mailing address is given, since your results will be sent to this address.

6 Telephone/Mobile number 7 email

8 Date of birth d d m m y y 9 Gender F M (circle as appropriate)

10 Please indicate which document you will be using as proof of identity and give the number below. Candidates taking the test outside their own country must present a current passport. You must bring the ID document indicated below to the test. This is the only form of identity that will be accepted on the test day. The document must be valid/not expired at registration and on the test day.

Passport National Identity Card

Passport or National Identity Card number

For office use only

scheme test date d d m m y y

date of payment d d m m y y receipt number

ID checked Administrator’s initials

For questions 11–14 please enter codes and the name of the country and first language. Codes can be found on pages ii–iv. Please take care and enter this information accurately. If the codes you enter here are incorrect, the information on your Test Report Form will also be incorrect.

11 Country or region of origin (code) 12

Country or region of origin (name)

12 First language (code)

First language (name)

13 13 Occupation (sector) if other, please specify

Occupation (level) if other, please specify

14 Why are you taking the test? if other, please specify

15 15 Which country are you applying to/intending to go to? (tick one box only)

Australia Canada New Zealand Republic of Ireland United Kingdom

United States of America other, please specify

16 16 Which IELTS test module are you taking? (tick one box only) Academic General Training Please note that it is the candidate’s responsibility to select the test module that best meets their needs. The General Training module is not available on every test date.

17 Have you taken IELTS (either Academic or General Training) before? yes no (go to question 18) (go to question 19)

19 18 Most recent IELTS test details: Centre name

Centre number date d d m m y y

20 19 Where are you currently studying English (if applicable)?

21 20 What level of education have you completed? (tick one box only)

secondary up to 16 years secondary 16–19 years degree or equivalent post-graduate

22 21 How many years have you been studying English? (tick one box only)

1 (less than) 2 3 4 5 6 7 8 9 or more

23 22 Do you have any special requirements due to ill health/medical conditions? yes no

If yes, please specify your requirements below. You must attach supporting medical evidence to this form.

Requests for modified test materials must be submitted at least 3 months before the test.

Notice to Candidates This notice has been written to help you. Read it carefully and do as you are asked. If there is anything you do not understand, ask the IELTS Administrator or the test supervisor.

Before test day – reproducing any part of the test in any medium. – attempting to alter the data on the Test Report Form. You must … • Candidates engaging in malpractice will not be allowed to complete the • provide proof of your identity (passport or national identity card) at test and will not receive an IELTS test result. Candidates who are found registration. This identity document must contain a number, a signature, a to have engaged in malpractice on test day after their result has been date of birth and a photograph. You should contact your test centre who issued will have their result cancelled. Candidates engaging in will tell you which type of identity document they accept. Candidates malpractice may be liable to legal action. taking the test outside their own country must produce a passport. • provide two recent identical passport-sized photographs on registration. Your test result (See page iv for guidance on photograph requirements.) • inform the test centre of any changes to your identity document before • Results are issued by test centres, usually 13 days after the test. the test date. If you do not do this you will not be allowed to take the test • You will receive only one copy of your Test Report Form. The test centre and you will not be eligible for a refund or transfer. is not permitted to issue a replacement copy in the event of loss or damage. On test day • The Test Report Form will be issued in your name as it appears on the identity document used at registration. If you find that your personal details are incorrect on the Test Report Form, please contact the centre where you You must … took the test to request changes. Documentation must be provided to verify • bring the same identity document on the test day as the one recorded the correct details. If the centre is unable to assist with your request for a on your Application Form. If you do not do this you will not be allowed to change to your personal details please contact either IDP (ielts@idp.com) take the test and you will not be eligible for a refund or transfer. or British Council (ielts@britishcouncil.org) for further advice. • arrive at the test centre before the scheduled test start time. If you • If you change your name after receiving your Test Report Form, the arrive late: name will not be changed on the Test Report Form. In the unusual event – you will not be admitted to the test room. that a replacement Test Report Form is approved centrally by the IELTS – you will not be allowed to take any of the test components. Test Partners, it will be issued with the name provided on the original – you will not be eligible for a refund or transfer. Test Report Form. • leave personal belongings outside the test room. The following items • Your result may not be issued 13 days after the test if any of the IELTS may not be taken into the test room: bags, correction fluid, highlighter Test Partners deem it necessary to review any matter associated with pens and electronic devices such as mobile phones, pagers, recorders your test. In exceptional circumstances you may be required to re-take and dictionaries. Candidates must ensure that mobile phones and one or more IELTS components. pagers which are left outside the test room are switched off. Any candidate who does not switch off their phone or pager, or takes any • The Test Report Form may be cancelled after it has been issued if any electronic device into the test room, will not be allowed to complete the irregularity is identified within the two-year validity period. You may be test and will not receive an IELTS test result or be eligible for refund or required to re-take one or more IELTS components. transfer. Candidates must not bring valuables to the test centre as the • Your result will be disclosed by the IELTS Test Partners to the test centre cannot be responsible for these. Recognising Organisations which you nominated on your Application • keep only the following items on your desk: your identity document, Form, for the purpose of allowing those organisations to verify the result pen(s), pencil(s) and eraser(s). or to carry out any enquiries in relation to suspected malpractice. • tell the test supervisor or invigilator at once: • If any of the data on the Test Report Form provided by you or your – if you think you have not been given the correct question paper. agent to Recognising Organisations has been altered in any way, your – if the question paper is incomplete or illegible. original test result will be cancelled by the IELTS Test Partners. • raise your hand to attract attention if you are in doubt about what you • You will not be permitted access to the work you produce in the IELTS should do. An invigilator will come to your assistance. Candidates may test. The IELTS Test Partners will retain the work you produce to assess not ask for, and will not be given, any explanation of the test questions. your test performance, and it may be used for quality control purposes and research activities. • inform the test supervisor or invigilator on the day of the test, if you believe that your performance may be affected by ill health, by the way in which the test is delivered at the centre or for any other reason. If you Cancelling your test or requesting a transfer have a complaint relating to the delivery of the test, you must submit your complaint to the test centre before your results have been issued. • If you cancel your test or request a transfer five weeks or more before The IELTS Test Partners will not accept complaints relating to the the test date, the test centre will charge an administration fee of up to delivery of the test after results have been issued. 25% of the total test fee. • when leaving the test room at the end of the test, leave behind all test • If you cancel your test within five weeks of the test date for any reason materials. The test materials include, but are not limited to, question apart from medical ones, you will not be eligible to receive a refund. If papers, Speaking tasks, answer sheets/booklets and any paper used for you cancel your test or request a transfer within five weeks of the test rough work. Any candidate who attempts to remove test materials from date for medical reasons, you must provide supporting medical the test room will be disqualified and will not receive an IELTS test evidence within five working days of the test date. Only evidence of result. serious illness will be considered. Only original medical certificates will be accepted and must state inability to appear for the test on the You must not … scheduled test date. • talk to or disturb other candidates once the test has started. • lend anything to, or borrow anything from, another candidate during the How IELTS uses your information test. • eat or smoke in the test room. • The IELTS Test Partners recognise and support the right of genuine • leave the test room without the permission of the test supervisor or IELTS test candidates to privacy. invigilator. • Test Report Forms will only be sent to those Recognising Organisations • leave your seat until all test materials have been collected and you have nominated by the IELTS candidate on their Application Form or at the been told you can leave. request of the candidate after the issue of results. • engage in any form of malpractice which may damage the integrity and • The IELTS Test Partners or their authorised representatives may share security of the IELTS test. Malpractice includes, but is not limited to: candidate test performance or score data with Recognising – attempting to cheat in any way. Organisations or law enforcement agencies where required for – impersonating another candidate or having another person verification purposes or other purposes to protect the IELTS test and its impersonate you. stakeholders against any form of malpractice. The IELTS Test Partners – copying the work of another candidate. may use IELTS test score data and test responses, in an anonymous – disrupting the test in any way. form, for informational, research, statistical or training purposes.

Codes to enter for questions 11–14

Refer to the lists below for the codes to enter for your country or region of origin, your first language and your occupation. If either your first language or your country or region of origin is not listed, enter '000'. Look for the closest description of your occupation and proposed area of study. If your work or position is not covered at all, then enter '00'.

Please turn over iii

Example If you are a student, enter 08 because the sector is Education and 7 because the level is Student.

0 8 7

Sector Administrative services 01 Agriculture, Fishing, Forestry, Mining 02 Arts and Entertainment 03 Banking and Finance 04 Catering and Leisure 05 Construction Industries 06 Craft and Design 07 Checklist Education 08 Health and Social Services 09 I have signed the Application Form. Installation, Maintenance and Repair Services 10 Law and Legal Services 11 Manufacturing and Assembly Industries 12 Personal Services 13 I have provided 2 passport-sized photographs Retail Trade 14 (signed on the back). Technical and Scientific 15 Telecommunications and the Media 16 Transport 17 Photographs must: Utilities (gas, water etc) 18 • be in colour Wholesale Trade 19 • be identical Other 00 • be no more than 6 months old Level • be taken against a plain background so that features are Self-employed 1 clearly distinguishable Employer/Partner 2 • be undamaged Employee (Senior level) 3 Employee (Middle or Junior level) 4 • be in sharp focus and clear Worker in the home 5 • be print quality of professional standard Retired 6 • be a close-up of the head and shoulders Student 7 Other 0 • show the candidate looking straight at the camera • show the candidate with a neutral expression • show the candidate with mouth closed • show the candidate with eyes open and clearly visible • show the candidate without glasses Question 14 – Why you are taking the test? • not show any shadows For higher education extended course 1 • not show anything covering the face, the outlines of the (three months or more) eyes, nose or mouth For higher education short course 2 (three months or less) For other education purposes 3 I have provided all the information required. For registration as a doctor 4 For immigration 5 For employment 6 For professional registration (NOT medical) 7 I have enclosed the test fee. For personal reasons 8 (Please note that your application will not be For registration as a nurse (including CGFNS) 9 processed without this). For registration as a dentist 10 Other 0

Please turn over 3

Declaration • I acknowledge that the IELTS test is jointly managed by British Council, IDP: IELTS Australia and Cambridge ESOL, collectively referred to as the IELTS Test Partners. • I certify that the information on this Application Form is complete, true and accurate. • I understand that the personal data on this Application Form is collected for the purposes of the IELTS test, and I consent for this data to be disclosed to, processed and stored by the IELTS Test Partners for the purpose of such administration. I further consent for this data and my test result to be disclosed by the IELTS Test Partners to those Recognising Organisations to which I apply, for the purpose of allowing these organisations to verify my test result or to carry out enquiries in relation to suspected malpractice. If the IELTS Test Partners discover that a false or altered Test Report Form has been provided to any of these Recognising Organisations I further consent that the IELTS Test Partners may inform the same and provide them with my personal data and any relevant details relating to the work I produce as part of my test taking. • I understand that my personal data may be processed in an anonymous form for statistical and research purposes for the development of Cambridge ESOL examinations. Cambridge ESOL and the centre administering the test confirm that they will not disclose personal information about candidates to others except as stated in this Declaration or to the extent permitted by law. • I understand that I may view a copy of my personal data contained in the Application Form by contacting ielts@cambridgeesol.org. I understand that a fee will be charged for access to this information. • I understand that if the details on this form are not completed my application may not be processed. I further understand that completing and submitting this Application Form does not guarantee enrolment on my preferred test date or at my preferred test location. I understand that my enrolment will be confirmed in writing from the test centre. • I acknowledge that I have read the IELTS Notice to Candidates contained on page i of this document and undertake to abide by the rules and regulations contained therein. • I understand that the IELTS Test Partners have a responsibility to all candidates and Recognising Organisations to ensure the highest confidence in the accuracy and integrity of test results and that the IELTS Test Partners therefore reserve the right to withhold test results temporarily or permanently, or to cancel test results which have been issued, if they consider those results to be unreliable for reasons of suspected malpractice or any other irregularity in the test process. • I understand that my result may not be issued 13 days after the test if any of the IELTS Test Partners deem it necessary to review any matter associated with my test, including making enquiries as to whether any rules or regulations have been breached, as outlined in the IELTS Notice to Candidates. I understand that in exceptional circumstances I may be required to re-take one or more IELTS components. • I understand that if I engage in any form of malpractice, or do anything that might damage the integrity and security of IELTS, I will not receive a test result, my test fee will not be refunded and I may be prohibited from taking the IELTS test in the future. I understand that details of any malpractice that has been established or is being formally investigated may be provided to the relevant Recognising Organisations, including visa processing authorities, and that suspected malpractice will be reported centrally to the IELTS Test Partners and to any relevant test centre by the centre where the suspected malpractice occurred. • I understand that if any other person attempts to take the IELTS test in my place (i.e. in place of the person whose details appear on this form), both I and such person will be liable to prosecution. Details relating to the situation may be provided to the relevant authorities, including visa processing authorities. • I consent for a photograph to be taken of me on the test day to assist in the confirmation of my identity. I acknowledge that this photograph will be printed onto the IELTS Test Report Form issued under my name and with my identity details and will be provided to the Recognising Organisations to which I apply and to the IELTS Test Partners. • I understand that the work I produce as part of the IELTS test remains the property of the IELTS Test Partners. Under no circumstances will it be released to candidates or to institutions or organisations, except in the investigation of suspected malpractice whereby the work I produce as part of the IELTS test may be provided to relevant authorities. • I agree that an observer may attend my Speaking test as part of the monitoring process. • I understand that I will be charged the full test fee if I cancel my test or request a transfer within five weeks of the test date, unless I provide appropriate medical evidence, within five days of the test date, to support the cancellation or transfer. • I acknowledge that I have read the IELTS Information for Candidates booklet.

Disclaimer: The International English Language Testing System (IELTS) is designed to be one of many factors used by academic institutions, government agencies, professional bodies and employers in determining whether a test taker can be admitted as a student or be considered for employment or for citizenship purposes. IELTS is not designed to be the sole method of determining admission or employment for the test taker. IELTS is made available worldwide to all persons, regardless of age, gender, race, nationality or religion, but it is not recommended to persons under 16 years of age.

British Council, IDP: IELTS Australia and Cambridge ESOL and any other party involved in creating, producing, or delivering IELTS shall not be liable for any direct, incidental, consequential, indirect, special, punitive, or similar damages arising out of access to, use of, acceptance by, or interpretation of the results by any third party, or any errors or omissions in the content thereof.